Provider Demographics
NPI:1194835801
Name:DE LA GARDELLE, JOLENE JOLENE (MPA)
Entity Type:Individual
Prefix:
First Name:JOLENE
Middle Name:JOLENE
Last Name:DE LA GARDELLE
Suffix:
Gender:F
Credentials:MPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5510 N HESPERIDES ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-5414
Mailing Address - Country:US
Mailing Address - Phone:813-467-6111
Mailing Address - Fax:
Practice Address - Street 1:5510 N HESPERIDES ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-5414
Practice Address - Country:US
Practice Address - Phone:813-467-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL766798100Medicaid